For Home Health Providers, Interoperability ‘Wins’ Have Become Crucial For Referral Relationships, Bottom Lines

For patients and providers, working through the post-acute health care system in the U.S. is a tall task.

It often involves a wide range of providers and vendors. There’s lots of talk around interoperability in these circles, but that goal of seamless coordination is generally not met on the ground.

Generally, interoperability refers to the ability of different health care information systems to communicate, exchange data and leverage that information in a way that provides effective care across a variety of health care settings, including home health care.


It has also become a near necessity for home health care’s referral sources, which are sending patients off to a wide variety of agencies.

In a study conducted in 2019 by ResMed and Porter Research, 64% of referral sources said they would switch which care providers they send patients to if they have an opportunity to achieve better interoperability.

In 2023’s version of the study, that number was 99%.


“Now, roughly every single referral source out there says, ‘I need more interoperability and I’m willing to try to influence where my patients go to achieve that,’” Nick Knowlton, VP of strategic initiatives at ResMed SaaS, said at the National Association for Home Care & Hospice’s (NAHC) annual conference Monday. “At the same time, 96% of survey respondents said that they would send more referrals to post-acute care providers with strong patient engagement capabilities. We’re starting to see the rise of the patient as a consumer and the rise of the importance of getting patients better connected to their own care.”

Clinical and financial interoperability

For home health providers, building strong relationships with referral sources is key, and interoperability is becoming a greater part of those relationships.

“We have several different referral sources,” Ken Albert, president and CEO of Androscoggin Home Healthcare & Hospice, said at the conference. “Navigating referrals is one thing. Having a partner that is able to express safety requirements and security requirements that are necessary for data exchange is very important. But also, the functionality to be able to build that chart effectively from a patient safety perspective to ensure we have all the data that’s necessary. That is an essential focus for what we do with interoperability.”

The Maine-based Androscoggin is a nonprofit operator that employs 500 workers across all 16 counties in the state. It works with health systems, SNFs, psychiatric hospitals and a number of other organizations as referral sources.

Androscoggin uses interoperability as a way to show value to its referral sources — both internally and externally.

“First and foremost, we use interoperability on multiple levels to create a value proposition for our referral sources,” Albert said. “We also use it from an internal perspective. We’re the only home health and hospice organization in the state of Maine that actually exchanges data with our state’s health information network. That’s a differentiator for us. That allows providers or emergency departments to be able to see, post-discharge, what’s occurring and actually happening in a 24-hour exchange.”

On the clinical side, Androscoggin leverages interoperability for things like DME management, pharmaceutical management and EHR efficiencies, among others.

The company is also leveraging the financial data of its patient population to better understand its payer sources.

“No margin, no mission,” Albert said. “That is something that nobody has the solution for, but we’re looking at all of our partners and all of our solutions together. We can aggregate that information in one data warehouse and then, with our team, build out those dashboards.”

There are four tiers of referrals that Androscoggin contracts with. Each payer contract fall into one of those tiers. The company then manages its budget based on the percentage of its patient population within each of those tiers.

“For tier four, which is our lowest payers, we only want 10% of our patient population in tier four,” Albert said. “If it gets to 11%, we take no more tier four, and our folks in the patient service center know that on a real-time basis. They’re pulling that data from our data warehouse that we manage through an interoperability network.”

Vital for smaller providers

For providers that are not a part of health systems, interoperability is crucial.

The Vermont-based Addison County Home Health & Hospice has firsthand experience in meeting the needs of a health system in order to shore up strong referral relationships.

“We have one large health system that surrounds us and we are not connected to that health system, so having interoperability that works with us is key,” Addison Home Health & Hospice CEO Deb Wesley said at the conference. “They have a very powerful EHR, so they were not going to bend to our will and help us with our interoperability. So we partnered with their EHR because we had to really try to accommodate and meet their needs.”

One of the biggest challenges out of the gate was wrangling all the data that is tied to a single patient.

“So many patients see so many physicians, in so many departments, that by the time we get that referral, they’re chopped up into disciplines and specialties and it’s really hard to put the pieces together,” Wesley said. “We work closely in our EHR so we can pull down all of the data, so that our clinicians have all the documentation for when they walk into that patient’s home.”

Sometimes it’s as simple as making sure clinicians and patients are on the same page about medication intake.

“The engagement around the fruit basket of meds with a patient or a family member has to be done one-on-one in the home,” Wesley said. “It can’t be done afterward, and it’s cumbersome. That is one of the leading reasons our patients will head back to the hospital, so we put a lot of focus on that. We use Surescripts, so at the time of referral, all the information is right there in the same place. It has really increased our efficiency in the home. It’s reduced the duplication and reduced the errors we see as well.”

Amid a tough time for home health providers, interoperability wins have become a positive development to point to.

“I’m not only excited for the interoperability that we’ve adopted that has really changed and transformed who we are,” Wesley said. “I get even more excited about the things that are coming down the road.”

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